Form C-5321 - Member Claim Form
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2MEMBER CLAIM FORM
Mail Station 1E238
PO Box 9291
Des Moines, Iowa 50306-9291
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A SEPARATE CLAIM FORM MUST BE SUBMITTED FOR EACH PATIENT WHEN SENDING BILLS TO WELLMARK BLUE CROSS AND BLUE SHIELD OF IOWA
PLEASE REFER TO THE INSTRUCTION ON THE BACK OF THIS FORM WHEN FILING YOUR CLAIMS.
Identification Number (as indicated on your identification card including the three-digit prefix)
Group Number
Patient’s information
Complete First Name
Date of Birth
Patient’s Last Name
MI
/
/
Gender
Patient’s Relationship to Policy/Certificate Holder
c Male
c Female
c Self
c Spouse
c Child
c Other (Specify)
Date Illness Began
Description of illness or injury requiring treatment
/
/
If yes, date of accident
Was this an automobile accident?
Was the illness/accident related to employment
Was this an accident?
/
/
c Yes
c No
c Yes
c No
c Yes
c No
Was patient a full time Student?
If yes, what school?
c Yes
c No
Other Insurance - This part must be completed in full before we can determine responsibilities for your claim
Do you have Medicare? Part A: c No c Yes; Effective Date ____/____/____
Part B: c No c Yes; Effective Date ____/____/____
If yes, please file the claim with Medicare first. Then submit a copy of your Explanation of Medicare Benefits with this form.
Is the patient covered by other medical insurance? c Yes
c No
If yes, and the policy is with a group (such as through an employer or Farm Bureau), please complete the following section.
Name of insured policyholder
Name and address of insured’s employer
Name and address of other insurance company
Policy Number (other insurance co.)
Type of coverage
Has the other insurance company paid?
If yes, please submit a copy of their payment information with
this form.
c Single
c Family
c Yes
c No
Policy/Certificate Holders Information
MI
Policy/Certificates Holder’s Last Name
Complete First Name
Policy/Certificate Holder’s Employer
Zip Code
Date of Birth
Policy/Certificates Holder’s Address
State
City
/
/
I certify the above is complete and correct and that I am claiming benefits for charges incurred by the patient named above. I authorize any
health care provider to release medical records to Wellmark Blue Cross and Blue Shield of Iowa when resonably related to the health care
claims submitted. If any law or regulation requires additional authorization for release of medical records, I will give this authorization.
Policy/Certificate Holder’s Signature_______________________________________________________
Date_____/_____/_____
Other Services and Supplies not Filed by Provider or Hospital (Attach a legible copy of original itemized receipts)
These may include office visits, hospital visits, physical therapy, diabetic supplies, ambulance services, medical appliances, etc.
If services were rendered outside the USA, please indicate:
Country
Currency Used
Date of Service
Description of Service / Supplies
Diagnosis or Symptoms you Sought Treatment For
Charge
(MM/DD/YY)
Provider Information
Tax ID
Name
NPI
City
Zip Code
Address
Place of Service
State
C-5321 2/15
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